The URL can be used to link to this page

Home My WebLink AboutBldp-20-002700 . ., MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ,, ar� �D— �.27��, _;"— CITY l y q J•-11Ar,Lit m t E rt) I MA DATE[40:41ID PERMIT# a70— 1 r ` OWNERSNAMEUI aira I f- �''� r JOBSITE ADDRESS I DLL, '�Ct I t°; t'�h OWNER ADDRESS I iF)(rO __,...,-...--.--1 TELWr+>r + 4 F mam IIIIIIIIIII TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL PRINT PLANS SUBMITTED; YES® NO +� �' CLEARLY NEW:ElRENOVATION:® REPLACEMENT: FIXTURES-1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 O BATHTUB ---- CROSS CONNECTION DEVICE --- — i. = a Mgr.rfl WI"= �� DEDICATED SPECIAL WASTE SYSTEM _ 111 riri DEDICATED GASIOILISAND SYSTEM - ! w a ,-Th-' DEDICATED GY WA _ -- -_EN OM MIIIMMlINii_1, num-minumlima lI.RoInMig=ww_a DEDICATED GREASE SYSTEM _ RECYCLE SYSTEM - _ R r _-�� -� - I,' _-- `) DEDICATED WATER RTER SYSTEM - -C" _DISHWASHER -- - - - r nm-o sMN- MI DRINKING FOUNTAIN - m' plA III El FOOD DISPOSER Sr0.111111111111.1..MOM lin MI MR low MN ME r FLOOR I AREA DRAIN _. .._,�_ ..__- _-- -_-_ -_ _ INTERCEPTOR(INTERIOR) - '1111.11.11=1111'WON MI MI KITCHEN SINK V LAVATORY ROOF DRAW SHOWER STALL SERVICE I MOP SINK TOILET u -- -_ —- MN On iliii - _. - WASHING MACHINE CONNECTION _ _ `J -" = 1.101.1111111111 MN'a NM WATER HEATER ALL TYPES I� - WATER PIPING ®=Ina MINI n 10 OTHER t. - _ - r �� •-_-.._--- .__�,__. _-,. _._... INSURANCE COVERAGE: NO `C which meets the requirements of MGL Ch.142. YES 0l have a current liability insurance policy or its substantial equivalent IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 BOND Ej n OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT accurate I hereby certify that all of the details and information I have submitted or entered regarding this application are true and with all to thenbest o s oy knowledge a and that all plumbing work and installations performed under the permit issued for this application will be in pliance he Massachusetts State Plumbing Code and Chapter 142 of the General Laws. J a. / PLUMBER'S NAME'STEPHEN A.WINSLOW , __ "LICENSE# 12298 SIGNATURE MPQ JP® CORPORATIONO#13281C (PARTNERSHIP®#I 1LLCD# COMPANY NAME(EF WINSLOW PLUMBING&HEATING I ADDRESS 8 REARDON CIRCLE --- ------- CITY(SOUTH YARMOUTH 1 STATE MA ZIP 102664 1 TEL 508-394-7778 - FAX 508-394-8256 CELLI NIA 1 EMAIL accounts a able efwinslow.com „r1 r)n The Commonwealth of Massachusetts 4 =i ="' 1,=16 Department of Industrial Accidents ;:�1; 1 Congress Street,Suite 100 4',4 1',= Boston,MA 02114-2017 e — 7 V g www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual):E.F. WINSLOW PLUMBING&HEATING CO., INC Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:508-394-7778 Are you an employer?Check the appropriate box: Type of project(required): LEI_I am a employer with 88 employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. 0 Demolition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Policy#or Self-ins.Lic.#:1909A Expiration Date:01/01/2020 Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify and a pai s nd pen !ties of perjury that the information provided above is true and correct ®Si nature: -°, Date: Phone#:508-394-7778 Official use only. Do not write in this area,to be completed by city or town official \ Q City or Town: Permit/License# ` Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: